INTRODUCTION: Percutaneous nephrolithotripsy (PCNL) is a minimally invasive procedure for treating large and complex kidney stones, often resulting in significant post-operative pain and increased opioid use. This study aims to compare pain scores between patients undergoing PCNL who did and did not receive a preoperative single-shot thoracic paravertebral block (PVB) at the post-anesthesia care unit (PACU) as the primary outcome. Secondary outcomes were patient-controlled analgesia (PCA) usage on post-operative day 1 (POD 1), total opioid consumption on PACU and POD 1, and post-operative nausea and vomiting (PONV). METHODS: A retrospective cohort study was conducted on the medical records of 341 patients who underwent PCNL from July 2014 to April 2016 in a single major academic center. PVB was administered at thoracic levels T7-9 using a volume of 20 cc of bupivacaine, ranging from 0.25% to 0.5%, to achieve the desired analgesic effect. RESULTS: After excluding 34 patients, the study included 123 in the no block (NB) group and 149 in the regional anesthesia (RA) group. There were no differences in demographics, including age, sex, weight and height, BMI, and indication for PCNL. The results revealed that the RA group experienced a statistically significant reduction in PCA usage in both crude and adjusted models (adjusted logistic regression analysis: OR = 0.19, 95% CI = 0.05-0.60; p = 0.008). However, there were no significant changes in total opioid consumption, pain scores, or incidents of PONV. CONCLUSION: The retrospective analysis did not reveal any discernible advantage in pain management associated with the use of PVB for post-PCNL analgesia, except for reducing the percentage of PCA narcotics used. Future investigations with larger sample sizes and meticulous control for surgical indications and complexity are imperative to accurately assess the efficacy of this block in the context of post-PCNL surgery.
Analgesia after thoracotomy is challenging but important as inadequate pain control may result in early postoperative complications and a higher risk for post-thoracotomy pain syndrome. The authors report the successful utilization of an erector spinae plane (ESP) catheter for post-thoracotomy analgesia in a 40-year-old female with two dual-leaded spinal cord stimulators (SCS) in the cervical and thoracic levels. Although thoracic epidural analgesia is the current standard, epidural catheterization may present with obstructive, mechanical, or infectious concerns in patients with SCS. The ESP block may be a preferable approach to postoperative analgesia after thoraco-abdominal surgery over the thoracic epidural for patients with SCS.
We report a case involving failed extracorporeal membrane oxygenation (ECMO) cannulation in the setting of critical airway stenosis secondary to a large anterior mediastinal mass. The most invasive management option, ECMO, was initially pursued solely to avoid manipulation of a critical airway in case of intubation failure or life-threatening airway bleeding. However, after unexpectedly failing cannulation in two separate cannulation sites with an impending respiratory collapse, awake fiberoptic or emergent rigid bronchoscopy was the remaining viable option. The patient was ultimately intubated via awake fiberoptic intubation even though this modality carried a high complication risk and potential mortality if failed. This case report illustrates both the potential role of ECMO within the airway management hierarchy and the persistent need for contingency planning should ECMO cannulation fail. With the recent enthusiasm for ECMO incorporation into difficult airway management, our report serves to highlight the very serious issue of cannulation failure. There is a limited amount of case reports describing ECMO failure in a critical airway, and little has been described about rescue methods when ECMO fails. Our goal is to remind readers that although ECMO can be an excellent rescue option for a critically ill patient, it cannot be viewed as a last line of therapy. If one is able to rapidly recognize impending ECMO cannulation failure and is prepared for cannulation failure, they can save invaluable time in a decompensating patient.
Split cord malformations are rare spinal dysraphisms in which 2 separate spinal cords are present. Despite its diagnosis in all age groups, split cord malformations are not well described. The clinical presentation and symptom severity are highly variable. Anesthesiologists may encounter patients with known or unknown split cord malformations without much information to guide clinical decision-making and procedural risks of neuraxial anesthesia. This is the first case to the authors' knowledge of utilizing a caudal epidural injection for pain management in a patient with a diagnosed split cord malformation.
Pain Management , Spinal Cord , Humans
This case report highlights the potential for adverse effects with the erector spinae plane (ESP) blocks. ESP blocks are an alternative to the traditional epidural and paravertebral block for postoperative analgesia due to their relative technical ease and seemingly safer profile. To date, few complications have been reported from ESP blocks or catheters. Despite its distance from the epidural space, epidural-like effects may still occur with ESP catheters, such as hypotension and motor blockade, as observed in this patient after abdominal surgery.
Nerve Block/adverse effects , Pain, Postoperative/drug therapy , Pelvic Neoplasms/surgery , Aged, 80 and over , Female , Humans , Paraspinal Muscles/innervation , Treatment Outcome
OBJECTIVE: The objective of this study is to discuss the presentation and diagnosis of a complicated jejunoileal diverticuli. CASE REPORT: The case of a 94-year-old woman with small bowel obstruction secondary to an impacted enterolith from a jejunoileal diverticulum is presented to illustrate the clinical picture and radiographic findings of complicated small bowel diverticula.
Diverticulum/complications , Ileal Diseases/etiology , Intestinal Obstruction/etiology , Jejunal Diseases/etiology , Aged, 80 and over , Diverticulum/diagnostic imaging , Diverticulum/surgery , Female , Humans , Ileal Diseases/surgery , Intestinal Obstruction/surgery , Jejunal Diseases/surgery , Radiography
Hydrogen peroxide is present in many natural waters and wastewaters. In the presence of Fe(II), this species decomposes to form hydroxyl radicals, that are extremely reactive. Hence, in the presence of Fe(II), hydrogen peroxide is difficult to detect because of its short lifetime. Here, we show an expanded use of a hydrogen peroxide quantification technique using leuco crystal violet (LCV) for solutions of varying pH and iron concentration. In the presence of the biocatalyst peroxidase, LCV is oxidized by hydrogen peroxide, forming a colored crystal violet ion (CV+), which is stable for days. The LCV method uses standard equipment and allows for detection at the low microM concentration level. Results show strong pH dependence with maximum LCV oxidation at pH 4.23. By chelating dissolved Fe(II) with EDTA, hydrogen peroxide can be stabilized for analysis. Results are presented for hydrogen peroxide quantification in pyrite-water slurries. Pyrite-water slurries show surface area dependent generation of hydrogen peroxide only in the presence of EDTA, which chelates dissolved Fe(II). Given the stability of CV+, this method is particularly useful for field work that involves the detection of hydrogen peroxide.
